I read the article regarding iron deficiency in toddlers (Your Voice, May 2009). Such a problem is of great importance. I
also know that with issues of global importance it is critical to stand back and study the entire problem before recommending
"the cure."
I would hope that many of the professionals who read this article shared my concern that the only solution offered was to
increase medical testing and have the children take a pill. Our reputation as a profession is at stake here. This is no small
matter. For the first year of life, we applaud the return to the natural diet of infants as the reason for iron deficiency
being less common in today's children under the age of 1. In the next breath, there is no mention of dietary assessment and
intervention for the children over the age of 1. Not a word. Let us pause. Let us pass the plate. May it contain appropriately
nutritious food. May it offer what no pill can provide; the chance of a lifetime of the use of food as nutrition. Let us remember
"supplement" comes after the essential is provided and a lack remains. Our efforts must begin at the table. In most cases,
I expect that they will end there.
Belinda Voit, MD
Fort Collins, Colo.
I am upset but not surprised that no one in the iron deficiency piece mentioned the most logical, healthiest, and cheapest
way to prevent iron deficiency in toddlerhood: continue breastfeeding. The problem of iron deficiency worsens as children
are moved off breast milk and onto cow's milk, so don't move to cow's milk! It's quite simple, was done for millions of years,
and is still done in most parts of the world. Even in the US, more toddlers are nursed into toddlerhood than most doctors
realize. If the numbers increased, so would toddlers with sufficient iron stores. The World Health Organization recommends
breastfeeding for at least two years, and beyond. It is time the American Academy of Pediatrics (AAP) agreed. In addition to being a pediatrician, I am a lactation consultant and a volunteer breastfeeding counselor. Mothers often tell
me that they were nursed until they were two, or that they still nurse their 2-year-old but are afraid to tell their doctor.
Nursing even a few times a day in toddlerhood offers so many advantages including protection from disease, continued comfort
and bonding as well as being a built-in multivitamin. I hope the day will not be too far away when we see healthy, happy,
nursing toddlers wherever we look.
Frances Weintraub, MD, IBCLC
Madison, Wis.
The authors respond:
We agree with Dr. Voit's comments that a nutritious iron-rich diet is the ideal way to prevent toddler iron deficiency. Nevertheless,
as we pointed out, a number of recent US studies have demonstrated that about 30% of 1- to 3-year-olds still suffer from iron
deficiency, and so require iron supplementation. Many toddlers are picky and finicky eaters, putting them at high risk for
iron deficiency and therefore increased lead absorption.
In response to Dr. Weintraub, although we are strong advocates of breastfeeding for as long as baby and mother are happy with
it, we do not agree that prolonged breastfeeding without iron supplementation will prevent toddler iron deficiency. The current
AAP recommendations state that breastfeeding infants require supplemental iron starting at 4 to 6 months of age, and supplemental
iron should be used if a term breastfed baby is unable to consume sufficient iron from dietary sources after 6 months of age.
Alvin N. Eden, MD
Representing AAP NY 2 Subcommittee on
Toddler Iron Deficiency
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